Drug-Resistant TB in India: Photographs by James Nachtwey

February 25, 2013 4:00 AM EST

India’s urgent battle against tuberculosis is almost invisible, until you start to look for it. Then you will find it everywhere: in the hospital down the street, in the corner pharmacy, in labs, offices, and schools. With some two million new cases each year, India has more TB patients than any other single country. The government is fighting this ancient, airborne bacteria in both small, far-flung villages and the some of the biggest cities in the world.

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And so when news hit in late 2011 that there were patients in India who had cases of TB that weren’t responding to any known drug, the alarm bells went off — loudly. The government has been providing free supervised drugs for TB across the country since 2006. But a TB sufferer can also walk into any number of pharmacies around the country and pick up a prescription to treat his or her own disease. Sometimes it’s the right combination of drugs. Sometimes it’s terribly wrong. As a result, like in other countries, more and more Indians have been developing or catching drug resistant strains of TB, and those strains are getting harder and harder to treat.

Last year, TIME photographer James Nachtwey and I visited Mumbai, India’s glitzy financial capital, and Bihar, one of India’s poorest states, to see what is happening on the frontline. The government is now working hard in both places – and many more like it – to stem the tide of both multi-drug resistant (MDR) and extensively drug resistant (XDR) TB. How that battle is won — or lost — could determine the fate of millions in India, and millions more around the world who are expected to contract MDR TB in the next few years.

Nachtwey has documented the global emergence of MDR and XDR TB in India, Cambodia, Lesotho, South Africa, Siberia, Swaziland and Thailand. You can see a multimedia project resulting from his earlier work at XDRTB.org.

James Nachtwey is a TIME contract photographer who has covered Sept. 11 and the 2011 Japanese tsunami, among other topics, for the magazine. He was awarded the 2012 Dresden Peace Prize.

Krista Mahr is TIME’s South Asia Bureau Chief and correspondent in New Delhi, India.

MDR-TB isolation wards in Drug Resistant TB Center, one for women and one for men, Patna, Bihar State, India. James Nachtwey People in Vietnam affected by Agent Orange, an herbicide used by American forces during the war to defoliate the forests in order to deny cover to the enemy. The active ingredient, dioxin, is extremely toxic and has caused several generations of children to be born with severe disabilities and deformations. Families in rural farming areas with affected offspring. Cam Lo District, Quang Tri Province. Heavily sprayed during the war as the Ho Chi Minh Trail ran through the region from Laos. James Nachtwey People in Vietnam affected by Agent Orange, an herbicide used by American forces during the war to defoliate the forests in order to deny cover to the enemy. The active ingredient, dioxin, is extremely toxic and has caused several generations of children to be born with severe disabilities and deformations. Families in rural farming areas with affected offspring. Cam Lo District, Quang Tri Province. Heavily sprayed during the war as the Ho Chi Minh Trail ran through the region from Laos. James Nachtwey — Patients in a TB isolation ward in impoverished Bihar state, which has one of India’s highest infection rates.James Nachtwey for TIME

Pulmonary wards, for women and men, Nalanda Medical College Hospital, a government facility in Patna, Bihar State, India. All patients have TB. Receiving medication from nursing students. One man is in the operating theater having dressing changed on a tube that drains fluid from his TB damaged left lung. James Nachtwey People in Vietnam affected by Agent Orange, an herbicide used by American forces during the war to defoliate the forests in order to deny cover to the enemy. The active ingredient, dioxin, is extremely toxic and has caused several generations of children to be born with severe disabilities and deformations. Families in rural farming areas with affected offspring. Cam Lo District, Quang Tri Province. Heavily sprayed during the war as the Ho Chi Minh Trail ran through the region from Laos. James Nachtwey People in Vietnam affected by Agent Orange, an herbicide used by American forces during the war to defoliate the forests in order to deny cover to the enemy. The active ingredient, dioxin, is extremely toxic and has caused several generations of children to be born with severe disabilities and deformations. Families in rural farming areas with affected offspring. Cam Lo District, Quang Tri Province. Heavily sprayed during the war as the Ho Chi Minh Trail ran through the region from Laos. James Nachtwey — Pulmonary wards for women and men at Nalanda Medical College Hospital, a government facility in Patna, Bihar State, India.James Nachtwey for TIME

MDR-TB ward in Group of TB Hospitals in Mumbai. Patients receiving daily injections. Patients having tubes put into infected lungs to drain them. James Nachtwey People in Vietnam affected by Agent Orange, an herbicide used by American forces during the war to defoliate the forests in order to deny cover to the enemy. The active ingredient, dioxin, is extremely toxic and has caused several generations of children to be born with severe disabilities and deformations. Families in rural farming areas with affected offspring. Cam Lo District, Quang Tri Province. Heavily sprayed during the war as the Ho Chi Minh Trail ran through the region from Laos. James Nachtwey People in Vietnam affected by Agent Orange, an herbicide used by American forces during the war to defoliate the forests in order to deny cover to the enemy. The active ingredient, dioxin, is extremely toxic and has caused several generations of children to be born with severe disabilities and deformations. Families in rural farming areas with affected offspring. Cam Lo District, Quang Tri Province. Heavily sprayed during the war as the Ho Chi Minh Trail ran through the region from Laos. James Nachtwey — Patients receive daily injections and have tubes put into infected lungs to drain them. James Nachtwey for TIME

An Indian man with TB has the dressing changed on a tube that drains fluid from his damaged lung.James Nachtwey for TIME

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